Fertility Cares

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Archive for the ‘Fertility’ Category

• 08.31.10  How The Fertility Centers Of New England Selects Embryos For Transfer

  

  By Lynette A. Scott, Ph.D. HCLD, Director, Assisted Reproductive Technology Laboratories

  Just as our physicians treat patients as individuals, the embryologists at The Fertility Centers of New England treat embryos individually. Similar to the physician who uses the patient’s history, physical examination, and laboratory assessment to obtain a specific profile of that patient, we obtain an embryo profile at specific time points following egg retrieval, insemination, and throughout the embryo culture (growing) process. We do this by growing each embryo separately in individually numbered, tracked drops so that scoring of individual embryos can be done sequentially on Day 1, 2, 3, and 5 following fertilization. This allows us to develop an individual profile for each embryo. Using this system called sequential embryo selection or SES, the profile of the developing embryo is recorded. The embryo with the highest score is then selected for transfer because the embryo with the highest score is the embryo with the maximum potential for implantation.

  Timing is critical so that meaningful comparisons can be made. Thus the embryologist will note what time a patient takes her hCG injection (trigger shot) and all scoring events are precisely timed from that point. This is why it is important to note what time you take your hCG injection and report it to the nurse at the time of oocyte retrieval.

  The day of embryo transfer and embryo selection is based on combined scores taken from Day 1, 2, and 3 of culture. We grow to Day 5, the blastocyst stage, only if we have a number of embryos that are “profiled as good” on Day 3. That number is based on the patient’s age, the cohort of embryos and the overall appearance of the embryos. There is no difference in pregnancy rates based on day of transfer corrected for who is having transfer on any given day. Some patients do better with a Day 2 transfer while others with a Day 3 or even Day 5 transfer and we use our scoring system to determine the day of embryo transfer

  What the Embryologist Scores:

  Day 1 Fertilization Check: The pronuclear (PN) score. We are looking for fertilized oocytes with: equality in nucleolar precursor body (NPB) numbers and alignment.

  Day 1 Early Cleavage: At 23-24 hours post insemination, the nuclear membranes of the pronuclei begin to break down and the pronuclei disappear and then the embryo cleaves to a 2-cell. Early cleavage is a good sign and it is used as an additive scoring point.

  Day 2: Embryos are scored for blastomere (cell) number, how many nuclei each cell has and how even the cell sizes are. The cell number is generally 2 cells or 4 cells, with a minority of 3-cell or >4 cell embryos, which have poor developmental potential. The nuclei in the blastomeres of 2 and 4 cell embryos are easily seen at this stage and this can help eliminate embryos with possible chromosomal abnormalities. Embryos are scored as having no nuclei visible, multi-nucleate (or fragmented nuclei) or one nucleus per blastomeres (the desired form). Equality of blastomeres size/volume is also recorded. Embryos in which there is no more than a 20% difference in size/volume between the blastomeres are designated “even”, and those having different blastomere sizes, are “uneven”. A 4-cell, even sized embryo with 1 nucleus per blastomere is the best.

  Day 3: Scoring on a 5-point system and includes cell number, fragmentation % and pattern and signs of multi-nucleation. Grade 1 embryos: 6-8 cells, correct cell sizes (a 6-cell embryo has 2 cell sizes), no fragmentation, no visible multi-nucleation; Grade 2, Grade 3, Grade 4, Grade 5, arrested or totally fragmented.

  Day 5: Day 5 blastocysts look like a signet ring with a band of cells in a ball and an inner cell mass, which is a clump of cells hanging into the cavity of the ball. These embryos have >100 cells which are not easy to count. The key feature of a blastocysts is the inner cell mass.

  We select embryos for transfer on either Day 2, 3 or 5 following insemination by combining the score for each day. In this way the embryos with the highest potential for implantation can be selected for transfer and if good quality embryos remain after transfer, they can be frozen (cryopreserved) for later use.

  Tags: blastocyst, blastomere, cleavage, embryo transfer, embryos, fertilization, fragmentation, hCG, nucleolar precursor body, pregnancy rates, profile, pronuclear, scoring
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• 08.23.10  DECODING THE MENSTUAL CYCLE

  

  By Danielle Vitiello, Ph.D., M.D., Board-Eligible Reproductive Endocrinologist

  Menstruation, or the period, is the result of an endless dialogue between the command centers within the brain (the hypothalamus and pituitary gland); the ovary and the uterus. In particular the uterine lining, the endometrium, is responsive to the growth and maturation hormones provided by the ovary. The two major hormones responsible for preparing the endometrium for pregnancy are estrogen and progesterone. They are present at different levels during the menstrual cycle and together, they drive endometrial preparation and promote early development of the fetus and placenta alike. If the embryo is the seed, then the endometrium is the soil.

  The menstrual cycle may be spoken of in terms of the two major players: the ovary and the uterus. Each player then can be subdivided according to function using ovulation (release of the egg from the ovary) as the gatekeeper for transitioning from one phase to the next. If pregnancy does not occur, the cycle begins anew.

  There are two ovarian stages – the follicular phase and the luteal phase. The follicular phase corresponds to the preparation of the follicle, the protective bubble in which the egg resides. The luteal phase corresponds to the action of the residual follicle after the egg is released.

  During the follicular phase, a single dominant follicle (and egg within) is selected from a collection of hundreds of eggs prepared for each cycle. The pituitary gland provides enough growth hormone for the development of one follicle unit. Out of the typical 200-500 follicles present each month, the hungriest follicle attracts the growth hormone (follicle stimulating hormone) and the other ones simply die off – it is the ultimate king of the hill game. The selected follicle unit is exposed to a flux of hormones which promote an orderly development of the egg within. As the egg and follicle develop, they produce the hormone estrogen.
  Estrogen has two key roles. Its first job is to act as a surrogate marker for the pituitary gland. Its increasing levels signal to the brain that a follicle has been selected and is growing appropriately. These levels then can be used to gauge egg maturity. Secondly, estrogen is a growth factor that prepares a nutrition-laden and thickened endometrium. The growth phase of the endometrium is known as the proliferative phase and it is coincident of development of the egg within the follicle.
  Eventually, the follicle receives the release signal from the pituitary gland in the form of a highly concentrated pulse of Leutenizing hormone (LH) which promotes a final maturation of the egg. There is a 36 hour window between the follicle receiving the signal and release of the egg. This time is needed for a final egg maturation and preparation for its release and eventual transit to the fallopian tube where it will await sperm for hopeful fertilization.

  This surge of LH also signals the endometrium to prepare for an anticipated embryo. The remaining, empty follicle begins to produce the hormone progesterone (progestation-al hormone). Progesterone initiates the endometrium into becoming a more hospitable environment for the developing embryo.
  If one were making a parallel to the building of a bridge over a body of water, estrogen would be the rafters to build the bridge both far and high. Progesterone is the rivet that secures the rafters to each other securing safe passage.

  This hospitality, however is short-lived. There is a window for the embryo to implant which lasts only 24 hours. If the embryo does not implant; then this cycle was for naught. The command center within the brain then signals the body to dispense with the endometrium and start anew. This signal to begin a fresh cycle manifests in actual menstruation, or the period.
  Ironically, often the period is thought of as the end of the menstrual cycle. In actuality, it is a time when the communications between the ovary and brain are in overdrive. As within the reproductive system, hope seems to spring eternal and the cycle continues.

  Tags: embryo, endometrium, estrogen. LH, follicle, menstrual, ovary, pituitary, pregnancy, progesterone
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• 08.10.10  Many women with irregular periods wonder if they have PCOS or Polycystic Ovarian Syndrome.

  

  By Robert M. Weiss, M.D., Board-Certified Reproductive Endocrinologist

  The truth is that there are many causes of irregular periods but PCOS is the most common cause. About 7% of the overall population, about 25% of young fertile women and over 50% of women with irregular periods have PCOS. So most women with irregular menses will turn out to have PCOS.

  If you have menstrual periods less frequently than every 35 days or more than 5 weeks between periods, you very well may have PCOS. Over 90% of women with PCOS also have some clinical evidence of androgen excess, including excess hair growth above their upper lip, chin, breasts, or abdomen, or acne. Most of these symptoms will start in the teen years. Certain ethnic groups with overall fewer body hair follicles don’t exhibit this, e.g., women of Asian descent. Specific blood tests can help identify elevated male hormones (androgens) in women.

  About 2/3 of women with PCOS will be overweight, although 1/3 of women with PCOS are normal weight. These thin women with PCOS are often surprised to find out they have PCOS as many believe that only overweight women have PCOS. Also many women with PCOS have some degree of insulin resistance, that is, elevated insulin with normal glucose levels, prediabetes or true diabetes. This needs to be tested by very specific blood tests in all women with PCOS.

  Although most women with PCOS have ovaries with many follicles or small cysts, not all women with PCOS have polycystic ovaries! An ultrasound is not always necessary for the diagnosis. In fact, many women with PCOS are advised they have normal ultrasounds from outside labs as radiologists are often looking for large ovarian cysts and are not necessarily looking for the many very small cysts seen with PCOS. Also, the many small cysts of PCOS are often the result of elevated insulin levels or other hormonal abnormalities. These altered hormone levels also cause irregular menses. The polycystic ovaries do not cause the syndrome but are caused by the other hormonal abnormalities.

  Of course, other diseases can cause irregular or infrequent periods and simple blood tests can identify these causes.Three common causes are hypothyroidism, elevated prolactin levels and pregnancy. Although some PCPs, or general OB/Gyns can diagnose and manage PCOS, Reproductive Endocrinologists are best at this. If you have questions about the diagnosis, feel free to blog me or ask your friendly reproductive endocrinologist. Next week I will discuss the management of PCOS.

  For more info: see Hormone.org, asrm.org, or pcossupport.org

  Tags: abnormalities, clinical evidence, common cause, cysts, hormones, irregular periods, ovaries, PCOS, polycystic, weight
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• 07.29.10  Endometriosis and Infertility

  

  By Danielle Vitiello, Ph.D., M.D., Board-Eligible Reproductive Endocrinologist

  Endometriosis is a common condition in women often associated with pain and infertility. It occurs when tissue that normally lines the inside of the uterus (endometrium) grows on the outside of it, mainly in the pelvis, ovaries and abdomen. Monthly hormonal changes can produce inflammation leading to pain and infertility due to the tissue itself or to the body’s reaction to inflammation by causing scarring around the reproductive organs, intestines, and other structures within the pelvis.

  The cause of endometriosis is unknown, although, many theories have been proposed. The most popular theory of what causes endometriosis is retrograde menstrual flow in which tissue shed during the period flows into the pelvis. Another plausible theory involves a genetic predisposition influenced by hormones or other signals causing a reaction of cells lining the pelvis, within the ovary, or elsewhere to differentiate into tissue that looks and acts like endometrium. Endometriosis is not a sexually transmitted disease nor is it caused by an infection.

  Regardless of the etiology of endometriosis, pelvic pain is the most common symptom occurring before, during, or after menstrual periods, or with, or after intercourse. Other common symptoms include lower back pain, fatigue, intestinal cramping, heavy bleeding with periods, and spotting between, or shortly before periods. Pain or bleeding with bowel movements or on urination may less commonly occur. Some women with endometriosis have no symptoms and only become aware of it when they have trouble becoming pregnant.

  The only definitive way to diagnose endometriosis is by having an outpatient surgery procedure called laparoscopy. This is a minor operation in which a reproductive surgeon looks inside the abdominal-pelvic cavity with a special camera.

  There is no cure as yet for endometriosis other than removing the source of its growth which is estrogen. Symptoms may be ameliorated by medications such as ibuprofen or naproxen which may reduce the inflammation and pain accompanying endometriosis. Continuous birth control pills, patches, or rings may shrink endometriosis tissue providing pain relief. Injections of leuprolide acetate can stop estrogen production by the ovaries thus shrinking endometriosis as well. Often when using leuprolide acetate a small dose of estrogen is given as ‘add-back’ to prevent the adverse side effects caused by lack of estrogen. These therapies can not be used when attempting pregnancy. In truculent cases, surgery may be necessary.

  Treatment decisions are more complex for those with endometriosis who are having difficulty becoming pregnant. In mild cases, coordination of intercourse with ovulation may be all that is necessary. Laparoscopic surgery for endometriosis in some cases may also facilitate pregnancy, although recurrence of endometriosis usually occurs within a year of surgery. For moderate and severe endometriosis, more advanced fertility treatments are often needed including in vitro fertilization (IVF). In the past, surgery was thought to be needed for endometriosis prior to having IVF, especially if endometriosis involved the ovary in the form of growths or large cysts called endometriomas. Recent evidence suggests that removing endometiomas prior to having IVF may remove too many small follicles potentially lessening the chance for pregnancy with IVF. Currently, most fertility specialists (Reproductive Endocrinology and Infertility, REI physicians) suggest laparoscopy prior to IVF only in an attempt to ameliorate pain. In cases where pregnancy is desired and the pain of this disease is not excessive, proceeding directly to IVF without prior surgery may afford the best chance for pregnancy.

  Endometriosis is associated with both physical and emotional distress, especially for women having difficulty becoming pregnant. Reproductive Endocrinology and Infertility Specialists provide the best source for treatment options and resources for support.

  Tags: abdominal pain, disease, endometriosis, endometrium, laparoscopy, ovaries, pelvis, reproductive endocrinologist, surgery
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• 07.21.10  Converting Follicle Stimulating Hormone (FSH)/Intrauterine Insemination (IUI) Cycles to In Vitro Fertilization (IVF)

  

  By R. Ian Hardy, M.D., Ph.D., Board-Certified Reproductive Endocrinologist, Medical Director

  For many couples, the inability to conceive is caused by abnormal or absent ovulation. Normal ovulation involves the natural recruitment of an egg that has been hibernating in the ovary since before birth. Ovulatory dysfunction is often corrected with hormonal medication which stimulates the ovary to ovulate. The hormone used is follicle stimulating hormone (FSH) which as the name implies is a hormone that stimulates the ovarian follicle. The follicle is a fluid-filled cyst which holds the ovulating oocyte (egg). The FSH stimulation is often combined with an intrauterine insemination (IUI) at ovulation in order to optimize fertilization.

  It is important to carefully monitor FSH IUI cycles with dosing adjustments as needed. Monitoring involves checking blood/serum hormonal levels of estrogen (estradiol) as well as ultrasound monitoring of both quantity and size of the maturing follicles which contain the oocytes. The intent of the hormonal stimulation is to enable and optimize the birth of a single healthy child – - not to get twins or triplets. Even with careful (in some cases daily) monitoring, the ovary will produce what is medically deemed to be an excessive number of oocytes. This can be associated with an unacceptably high risk of multiple births. In these cases, the couple will be given the option to cancel the cycle (no sperm – - no triplets) or instead to convert to an in vitro fertilization (IVF) cycle. In an IVF cycle, the follicles are aspirated under ultrasound guidance to retrieve the oocytes. The oocytes are fertilized outside of the body and in a controlled fashion a single embryo can be transferred to the uterine cavity. Any remaining viable embryos of good quality can be cryopreserved.

  In September 2005, the Fertility Centers of New England published an abstract looking at our own experience with IUI to IVF conversions (“Should High-Responding Gonadotropin IUI Cycles be Converted to IVF in an Insurance Mandated State?” R.I. Hardy, S. McLellan, K. Delegge, J.A. Hill, L. Scott Fertility and Sterility September 2005 (Vol. 84 Supplement 1, Page S310). The abstract was presented at the annual international meeting of the American Society for Reproductive Medicine. The study reviewed pregnancy rates in high-responding FSH IUI cycles emergently converted to IVF. Four patient groups (divided into > and < 38 y.o.) were analyzed for delivery rates: 1) first time IUI cycles 2) total (1-3) IUI cycles; 3) IUI cycles emergently converted to IVF due to ≥ 5 mature follicles present after stimulation; and 4) first time IVF cycles. The delivery/ongoing pregnancy rates were computed. The data is presented in the table below.

  

  * P<0.01, ** P<0.001

  The authors concluded that high-responding FSH/IUI cycles should be converted to IVF. The increased pregnancy rate in this converted group as compared to first time IVF patients also suggests possible effects of patient selection, down-regulation or FSH acclimatization. The favorable pregnancy rates in the converted cycles also prompted re-evaluation of required FSH/IUI treatment prior to IVF approval in insurance mandated states.
  If you have further questions or clinical concerns, feel free to speak with your physician regarding treatment options.

  Tags: converting, cycles, follicle stimulating hormone, follicles, FSH, IUI, IVF
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• 07.06.10  Ovarian Reserve

  

  By Joseph A. Hill, III, M.D., Board-Certified in Reproductive Endocrinology and Infertility

  “Ovarian Reserve” is a term referred by many infertility specialists to describe the size, quality and developmental potential of the eggs remaining in the ovary. As a woman age’s ovarian reserve diminishes and the chance of a chromosomal abnormal egg and thus the potential for miscarriage increases. As a result, older women are less likely to become pregnant and are progressively more likely should they become pregnant to have a miscarriage. Approximately 13% of women under age 35 desiring pregnancy will have difficulty having a baby and a similar percentage of those pregnant will have a miscarriage. While 25% of women age 35-39 will have difficulty conceiving, by the age of 40, 34% of women attempting pregnancy will have difficulty and approximately 26% of those over age 40 who are pregnant will have a miscarriage. In some women, ovarian reserve and fertility decreases earlier than expected. Predisposing factors include smoking, endometriosis involving the ovary, ovarian surgery, chemotherapy, and radiation. Some women may have a genetic predisposition, suggested by their mother’s or their sister’s early menopause or related to being a carrier for Fragile X. In most women, no cause for diminished ovarian reserve can be identified. Alterations in menstrual cycle length may be one of the earliest indicators of reproductive aging, but most women with decreased reserve have no change in their menstrual pattern.

  The simplest and most common “ovarian reserve” test is determination of a hormone made in the pituitary gland called follicle stimulating hormone (FSH) which is as the name suggests a hormone that is secreted to induce the ovary to make a follicle leading to a mature (ready to be fertilized) egg. The concentration of FSH in the serum obtained by venopuncture is ideally obtained on the 2nd, 3rd, or 4th day following the onset of menstrual flow. In most laboratories, FSH values greater than 10-15 IU/L are thought suggestive of diminished ovarian reserve. The serum estradiol concentration, obtained concurrently with FSH is also important since elevated levels (>75-80 pg/mL) may lower FSH concentrations below values that would otherwise suggest diminished ovarian reserve. Many fertility physicians use the clomiphene citrate challenge test (CCCT) as a method to assess ovarian reserve by measuring the serum FSH level again on cycle day 10 after taking 100 mg/day of clomiphene citrate (Clomid, Serophene) on cycle days 5-9. An abnormally elevated cycle day 2-4 FSH or estradiol concentration or stimulated (cycle day 10) FSH level (>10-15 IU/L) suggests diminished ovarian reserve. Other proposed but less well established hormonal indicators of decreased ovarian reserve include a low serum anti-mullerian hormone or inhibin B level, and a poor estradiol response to stimulation with FSH medications or gonadotropin-releasing hormone (GnRH) agonist stimulation. Ultrasonic indicators of diminished ovarian reserve obtained by a vaginal probe ultrasound examination include a decreased ovarian volume or antral follicle count, and reduced ovarian vascularity (blood flow).

  Ovarian reserve testing has some value for predicting ovarian response to fertility treatments (ovarian stimulation) and may help in planning therapy (ovulation induction for IUI or IVF). However, the accuracy of these tests is limited especially in women under age 40. An abnormal test result may suggest decreased probability of success, but does not absolutely predict failure. Ovarian reserve testing does provide important information, but age and previous fertility or response to gonadotropin therapy (FSH, LH, hMG stimulation) have greater relevance and predictive value. Women with mildly abnormal results may have a lower fertility potential but they are not sterile. Therefore like all test results they should be interpreted, explained, and applied with caution, sensitivity and compassion.

  Tags: agonist stimulation, antral follicle count, diminished ovarian reserve, FSH, gonadotropin, hormonal indicators, hormones, ovarian reserve, ovarian volume
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• 06.24.10  AIR TRAVEL

  

  By Joseph A. Hill, III, M.D., Board-Certified in Reproductive Endocrinology and Infertility

   

  Patients recently pregnant following infertility therapy often ask if air travel is safe during pregnancy.  While definitive studies in pregnant women following infertility therapy have not been published, a number of well designed studies in pregnant women form  the general population have confirmed that air travel is generally safe during an uncomplicated pregnancy. 

  A recent Committee Opinion No. 433: Air Travel During Pregnancy by the American College of Obstetricians and Gynecologists (ACOG) first published in 2001 and updated in the Journal, Obstetrics and Gynecology in 2009 stated, “ In the absence of obstetric or medical complications, pregnant women can observe the same precautions for air travel as the general population and fly safely.” 

  Even the longest intercontinental flights will expose passengers to no more than 15% of the limit of cosmic radiation exposure recommended by the National Council on Radiation Protection and Measurements and the International Commission on Radiological Protection.  The risks to the fetus from  exposure to cosmic radiation is negligible.  It is possible, however, that flight crew personnel and individuals who are frequent flyers may exceed the recommended limit of exposure.  The Committee also recommends that pregnant women who have medical or obstetric conditions that could be exacerbated by flight such as a tendency for venous stasis and thrombosis (blood clots) or that could require emergency care ( threatened miscarriage, vaginal bleeding, preterm labor) not fly at any time during their pregnancy. Most commercial airlines allow pregnant women to fly up to 36 weeks of gestation.

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• 06.11.10  What is a Fertility Specialist?

  

  By Joseph A. Hill, III, M.D., Board-Certified in Reproductive Endocrinology and Infertility

  A Fertility Specialist practices in a subspecialty within Obstetrics and Gynecology called Reproductive Endocrinology and Infertility. While any physician with a medical degree can claim to be a Fertility Specialist, only the American Board of Obstetrics and Gynecology (ABOG) can certify a physician in Reproductive Endocrinology and Infertility and only such certified Fertility Specialists can hold membership in the Society for Reproductive Endocrinology and Infertility (SREI). Some patient-oriented advertisements promote the infertility treatment experience of a physician without any mention of their qualifications and certification to provide such care. Still others professing to be Fertility Specialists may have completed subspecialty training yet never went through the rigorous process of attaining certification by ABOG. To become a certified Fertility Specialist the physician trains in reproductive science for an additional seven years after graduating from an accredited medical school. First, they must complete a four year accredited residency training program in Obstetrics and Gynecology. They then must achieve certification in Obstetrics and Gynecology after passing a written examination upon completion of their residency followed by an oral examination in Obstetrics and Gynecology, after an additional minimum of one year of independent specialty practice. Then to be eligible for certification as a Fertility Specialist in the subspecialty of Reproductive Endocrinology and Infertility by ABOG, the Fertility Specialist to be must successfully complete an additional three years of subspecialty reproductive science training in an ABOG accredited Reproductive Endocrinology and Infertility Fellowship Program. They then must pass a second written examination in Reproductive Endocrinology and Infertility followed by a second oral examination in Reproductive Endocrinology and Infertility and must successfully defend a published thesis of their independent work in reproductive science after a minimum of one year in independent subspecialty practice. There is no substitute or training equivalent for certification other than that under the auspices of ABOG. Physicians who falsely claim to have subspecialty certification in Reproductive Endocrinology and Infertility are subject to legal actions by ABOG. Calling oneself a Fertility Specialist should indicate one’s qualifications and certification in this subspecialty but it does not. However, for those experiencing the physical, emotional, and, social challenges of infertility, they can be assured that if their chosen Fertility Specialist is certified by ABOG in Reproductive Endocrinology and Infertility that he/she is indeed a Fertility Specialist and qualified to handle the complex medical issues involving hormonal imbalances in the reproductive system, infertility, recurrent pregnancy loss, and to provide the potential treatments that might be needed including reproductive surgery, ovulation induction, and IVF. Listing of certified Reproductive Endocrinology and Infertility Specialists can be found at ABOG.org or SREI.org

  Tags: ABOG, board certified, IVF, ovulation induction, reproductive science, reproductive surgery
  Posted in Fertility | 1 Comment »

• 06.04.10  FERTILITY DRUGS AND OVARIAN CANCER

  

  By Joseph A. Hill, III, M.D., Board-Certified in Reproductive Endocrinology and Infertility

  Over the years, controversy has existed whether fertility drugs can predispose to ovarian cancer. Several small poorly designed studies published in the 1990s raised the concern that drugs used to stimulate the ovaries and induce ovulation increased the risk of later developing ovarian cancer. Most recent studies have tended to suggest otherwise and the largest study to date was published (BMJ 2009;338:b249) by a Danish group from hospital and private fertility clinics involving 54,362 women with infertility treated between 1963 and 1998. Analysis showed no increased risk of ovarian cancer related to any fertility drug including use of clomiphene citrate (Clomid, Serophene), gonadotropins (FSH,hMG), human chorionic gonadotropin (hCG), and gonadotripin releasing hormone (GnRH). There was also no increased risk of developing ovarian cancer even in women who had undergone 10 or more treatment cycles with these drugs or in women who never became pregnant despite their use. These finding should reassure women who have been treated for infertility that ovulation induction drugs do not increase their risk for ovarian cancer.

  Tags: fertility drugs, ovarian cancer, risk, studies
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• 05.21.10  Elective Single Embryo Transfer (eSET): Rethinking the “one pregnancy and done” philosophy

  

  By Danielle Vitiello, Ph.D., M.D., Board-Eligible Reproductive Endocrinologist

   

  Many couples with infertility both desire and welcome the birth of twins, thus affording an instant family often after years of frustration, disappointments and inability to conceive adopting a “once and done” motto. Limitations of insurance coverage and increasing competition amongst infertility centers demands that pregnancy be achieved in as few cycles as is possible. Such pressures often culminate in the transfer of multiple high-quality embryos.
  As a result, these treatments now are responsible for 50% of twin births and 75% of higher-order births. The inherent risk of a multiple-gestation pregnancy to both mother and fetus(es) alike are not trivial, and increase dramatically when fetuses share a uterus. The most common maternal risks include: pregnancy-associated hypertension, gestational diabetes and Cesarean delivery. The most worrisome obstetric complications include: premature membrane rupture, premature birth, incomplete organ maturation and compromise as well as placental abruption. Both individually and in combination, these issues can cause significant morbidity and possible mortality. Rooted in the desire to promote maternal and fetal well-being, our profession is driven to develop both philosophies and technologic methods that reduce the frequency of multiple gestations and higher order (>2) pregnancies. Ultimately, the goal of ART (assisted reproductive technologies) is the delivery of a single, healthy child.
  The most effective means for reduction is the promotion of an elective, single-embryo transfer (eSET). The concept of eSET is not new and is presented as a reasonable response to the high proportion of multiple pregnancies generated. The philosophy of eSET, and the inherent need to maintain pregnancy success while limiting the number of embryos transferred, has called the field to address various aspects of single-embryo transfer. Refinement of both embryo selection techniques and evaluation of patient candidacy for eSET demonstrate that it is effective in maintaining pregnancy rates while reducing significantly the number of higher-order pregnancies. Furthermore, as an application, eSET allows us to study the relationship between individual embryo characteristics and implantation. Expanding our understanding of these intricate processes of embryo development and implantation will afford greater success in the future.
  eSET is not just a philosophy but also a viable concept in action. In Europe where eSET is implemented widely, the rates of multiple gestations have dropped. There was no significant decrease in the pregnancy rate although this potential outcome was much feared and anticipated. Our results at The Fertility Centers of New England supports the European experience as patients in whom we have done eSET have a greater than 40% on going pregnancy rate even in women up to the age of 37.
  eSET is effective and promotes fetal well-being. These infants have fewer obstetric and neonatal issues. In fact, babies born from eSETs do better than babies born from multiple embryo-transfers even when there is a single fetus in utero. In fact, they perform as well as those singleton infants conceived naturally.
  Eagerly, we await wide patient-acceptance of eSET. It is anticipated that patient confidence will grow as we demonstrate both clearly and continually, that it is possible to select the best embryo for transfer. As we work toward bettering reproductive science infertility treatments become more successful; and most importantly, we promote good pregnancies and healthy children.

  Tags: embryo transfer, IVF, maternal risk, multiple births, Obstetric complications, pregnancy success, Single Embryo Transfer (eSET)
  Posted in Fertility | 1 Comment »